Throat pack insertion

The National Patient Safety Agency (NPSA) recommends a number of methods to

reduce the risk of a throat pack (TP) being inadvertently left in situ. As part of these

recommendations they suggest that one of two methods be used in all cases. Which of

the following options contains BOTH of these suggested methods?

 

a) Placing a visible label on the patient stating a TP is in situ and removing it when

the TP is removed, or placing a label on the airway device (LMA or endotracheal

tube) stating a TP is in situ.

b) Tying one end of the TP to the airway device, or recording insertion and removal of

the TP as part of the formal swab count

c) Recording insertion and removal of the TP as part of the formal swab count, or

performing a formalised two-person check of the insertion and removal of the TP

d) Leaving part of the TP protruding externally, or putting a visible label or mark on

the patient stating a throat pack is in situ

e) Recording insertion and removal of the TP as part of the formal swab count, or

attaching the TP securely to the artificial airway device

Answer: c

Explanation

A joint working party including the National Patient Safety Agency (NPSA), the Royal

College of Anaesthetists, and the Association of Anaesthetists of Great Britain and

Ireland has examined the evidence for and methods to prevent the inadvertent retention

of throat packs (TPs). Of 63 270 recorded incidents in 2006 and 2007 the NPSA

identified 38 that were related to TPs of which one resulted in moderate harm to the

patient. Twenty-four of the incidents were related to inadvertent retention, the rest

related to the act of insertion itself. The report questioned the need for a TP in the vast

majority of cases. The working party recommended six methods to reduce TP retention,

and that two methods should be employed for each TP insertion. Of these, one of

either recording the TP insertion as part of the formal swab count, or performing a

formalised two-person check of TP insertion and removal should be used in each case.

The other four methods are putting a label or mark on the patient, putting a label or

mark on the airway device, securely attaching the TP to the airway device, or leaving

part of the TP protruding externally.

Reference

National Patient Safety Agency website. Online at www.npsa.nhs.uk (Accessed 30

October 2009)